Canada Drugs Online

202A, 8322-130th Street Surrey, British Columbia Canada. V3W 8J9

Tel: 1-877-900-3784 Fax: 1-866-364-9983

STEP 1:

Please complete this form, all fields with * must be filled out to be valid. Read and sign the Authorizations and Release Form. All information provided will be kept confidential.

STEP 2:

Mail your prescription or have your Doctor fax the prescription to us directly.

STEP 3:

Return completed form to us by fax, mail or email.

Canadadrugsonline 202A, 8322-130th Street Surrey, British Columbia V3W 8J9, Canada

Please be advised to contact 2-3 weeks prior to requirement of refill prescriptions.

*MEDICATIONS BEING ORDERED

* Please note that all prices and quantities will be confirmed with you before processing your order.

BRAND GENERIC

MEDICATION NAME

_______________ _______________ _______________ _______________

DOSAGE

_________ _________ _________ _________

QUANTITY

_________ _________ _________ _________

*HOW DID YOU FIND ?

Internet (link, search engine, etc.)

Print Ad

Referred by:______________

Other

Doctor

*HAVE YOU PREVIOUSLY FILLED OUT THIS FORM?

(Please check one appropriate field)

Yes

No

If yes please describe any changes to your health, medications, or exercise routine since the last time you gave information:

Please print clearly and FAX to: 1-866-364-9983 or MAIL to: 202A, 8322-130th Street, Surrey, British Columbia, Canada. V3W 8J9

YOUR HEALTH IS OUR CONCERN.

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*PATIENT INFORMATION FORM:

* Fields must be filled to be valid

*Last Name:

*Telephone: ( ) *E-Mail Address:

*City:

*Date of Birth (mm/dd/yy): / Age:

*Height: ft. inches

*First Name:

*Alternate No: ( ) *Mailing Address: Apt #/Street:

*State/Zip Code:

**Sex Male Female

*Weight: lbs.

*WHAT MEDICAL CONDITION(S) ARE YOU BEING TREATED FOR?

Acid Reflux Alzeimer's Disease Anemia Asthma Blood Disease Blood Pressure

Cancer Cholesterol Depression/Anxiety Diabetes Epilespy Fluid Retention

Heart Disease HIV/AIDS Kidney Disease Schizophrenia Liver Disease Migraines

Menopause Osteoporosis Tobacco Use Thyroid Disorder Ulcers

OTHER/COMMENTS:

*DO YOU SMOKE?

*DO YOU DRINK ALCOHOL?

Yes

No

Yes

No

*ARE YOU PREGNANT OR BREASTFEEDING AT THIS TIME?

Pregnant

Breastfeeding

No

Please print clearly and FAX to: 1-866-364-9983 or MAIL to: 202A, 8322-130th Street, Surrey, British Columbia, Canada. V3W 8J9

YOUR HEALTH IS OUR CONCERN.

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*PLEASE INDICATE ANY DRUGS ALLERGIES THAT YOU MAY HAVE:

*PLEASE LIST BELOW ALL PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS THAT YOU ARE CURRENTLY USING:

MEDICATION NAME _____________________

DOSAGE ______________

QUANTITY _______________

_____________________

______________

_______________

_____________________

______________

_______________

_____________________

______________

_______________

*PAYMENT OPTIONS Money Order

Certified Check

Billing Address (if different from above) Street Address: City:

Suite #: Zip / Postal Code: State/Province:

Note: There is a $10 shipping fee per order. *AUTHORIZATION AND RELEASE FORM: *Patient Signature:

*Witness Signature:

*Patient Printed Name:

*Witness Printed Name:

*Date:

*City/Town where signed:

By signing above, each time you place an order with us, you acknowledge and agree to the following:

Please print clearly and FAX to: 1-866-364-9983 or MAIL to: 202A, 8322-130th Street, Surrey, British Columbia, Canada. V3W 8J9

YOUR HEALTH IS OUR CONCERN.

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I agree to all of the following terms and conditions on behalf of myself, my heirs, assigns and successors. I further represent that I understand all of the following terms and conditions and that I have had adequate opportunity to consult any advisors necessary, whether medical, legal or otherwise. In the event that I am placing the order on behalf of someone else, I also represent that I have all necessary consent, permission and authorization to do so on behalf of that person and their heirs, assigns and successors.

LEGAL STATEMENT AND TERMS OF SERVICE

1. The Sale of Products are governed by the laws of the jurisdiction from which the products are shipped to me (unless elects otherwise at its sole discretion), without regard to conflict of laws principles.

2. By using the website, , I acknowledge and accept that products purchased from the website are dispensed from the following countries by the corresponding dispensaries which are partnered with :

CANADA Dispensary: Candrug, #202-8322 130th Street, Surrey, BC V3W 8J9, Canada. Regulatory Authority: College of Pharmacists of British Columbia

INDIA Dispensary: Moirae Generics Pvt. Ltd. B-710, Sagar Tech Plaza Sakinaka Junction, Andheri (E) Mumbai - 400 072, India. Licensing Authority: Assistant Commissioner, Food and Drug Administration, Mumbai Maharashtra Dispensary: Lawrance Walter, 3rd Floor Plot No. 3, 4 & 5 LSC, "J" block, Ashok Vihar Phase I, New Delhi ? 110052, India Licensing Authority: Assistant Commissioner, Food and Drug Administration, Delhi

MAURITIUS Dispensary: Zapatero International, Mer Rouge, Port Louis, Mauritius Regulatory Authority: Ministry of Health & Quality of Life Mauritius

NEW ZEALAND Dispensary: Medication Management Hub, 212 Wairau Rd Glenfield Auckland NORTH ISLAND New Zealand 0627 Regulatory Authority: Ministry of Health, New Zealand

SINGAPORE Dispensary: Alps Pharmacy, Alps Avenue, #03-01 Lian Soon Amenity Centre Singapore 498787 Regulatory Authority: Health Sciences Authority, Singapore

TURKEY Dispensary: CAN Pharmacy, Kosuyolu Cad., No:150, Kadikoy, Istanbul, Turkey Regulatory Authority: Provincial Health Administration, Republic of Turkey, Governorship of Istanbul

UNITED KINGDOM Dispensary: London Pharmacy Unit 13 Derby Rd. IND EST. Hounslow TW3 3UH., UK Regulatory Authority: Royal Pharmaceutical Society of Great Britain

Please print clearly and FAX to: 1-866-364-9983 or MAIL to: 202A, 8322-130th Street, Surrey, British Columbia, Canada. V3W 8J9

YOUR HEALTH IS OUR CONCERN.

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Please note from time to time we may dispense from other approved licensed dispensaries that are not included in the list above. Our customer service department will be happy to provide you with the exact dispensing pharmacy when you place your order.

3. Products sold by from its Partnered Dispensaries are predominantly purchased from outside the USA. This means that the packaging may be different to that available in stores in USA. You agree to accept the products `as is' and will not object to this.

4. accepts no liability for the contents for the website or any of the products sold. 's liability for any product which is defective or causes loss or damage of any kind is limited to the cost of the product or the provision of a replacement.

5. It is your responsibility to ensure that your use of and the purchase of any products from comply with the law where you are. makes no representation or warranty in this regard.

6. Prescription products cannot be returned or replaced.

7. By using and purchasing products from , you agree that you are not doing so for the purposes of taking legal action against .

8. Prices are subject to change without notice.

AUTHORIZATION AND CONSENT

I hereby appoint as my agent and attorney for the limited purpose of taking all steps and signing all documents on my behalf necessary to obtain a prescription in the country where the dispensary is located that is the equivalent of the prescription that I sent to (the `Equivalent Prescription') to the same extent as I could do personally if I were present taking those steps and signing those documents myself. This authorization shall include, but not be limited to, collecting personal health information about me, collecting similar information from my prescribing physician or pharmacist, and disclosing that personal health information to , its employees, agents, affiliates and service providers, including without limitation any authorized physician licensed in the country where the dispensary is located and any dispensary or pharmacist being retained by on my behalf (collectively the ` Agents'), as required for the limited purpose of obtaining the Equivalent Prescription and filling my Order.

DISCLOSURE AND REPRESENTATIONS

I represent that all of the following statements are true and understand that

, it's Partnered Dispensaries, their employees and contractors (physicians

and nurses, pharmacists and pharmacy technicians) are relying on the following representations:

1.

I am of the age of majority or older according to the laws of the state in which I reside ("My Place

of Residence").

2.

I can make my own medical decisions according to the laws of My Place of Residence.

Please print clearly and FAX to: 1-866-364-9983 or MAIL to: 202A, 8322-130th Street, Surrey, British Columbia, Canada. V3W 8J9

YOUR HEALTH IS OUR CONCERN.

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